Efficacy of combined ethinyloestradiol (0.035 mg) and cyproterone acetate (2 mg) in acne and hirsutism in women with polycystic ovary syndrome

Cyproterone acetate or drospirenone containing combined oral contraceptives plus spironolactone or cyproterone acetate for hirsutism: randomized comparison of three regimens

OBJECTIVE

To compare the effectiveness of three different combinations of combined oral contraceptives (COCs) and anti-androgens in the treatment of hirsutism.

METHODS

A total of 134 women with moderate and severe hirsutism were randomly assigned to three treatment regimens: Group I received 30 μg of ethinyl estradiol (EE)/3 mg of drospirenone (DRSP) plus 100 mg of cyproterone acetate (CPA) (n = 45); group II received 30 μg of EE/3 mg of DRSP plus 100 mg of spironolactone (n = 44); and group III received 35 μg of EE/2 mg of CPA plus 100 mg of CPA (n = 45), daily for 6 months. The decrease in the modified Ferriman-Gallwey hirsutism score (mFGS) was the main outcome measure.

RESULTS

The mean decrease in mFGS after 3 and 6 months of the treatment course was 26% and 49% in group I (both p < 0.01), 27% and 49% in group II (both p < 0.01), and 25% and 45% in group III (both p < 0.01), respectively, when compared with baseline. Although the mFGS was significantly decreased in all groups, there was no significant difference between groups.

CONCLUSION

CPA or DRSP containing COCs in combination with CPA or spironolactone have similar effects for the treatment of hirsutism.

Management of hirsutism

This review reports our own experience with, and literature studies of, the pharmacological management of hirsutism in women with hyperandrogenism (polycystic ovary syndrome) or with normal serum androgen levels and regular ovulatory menstrual cycles (idiopathic hirsutism). Treatment consists of suppressing ovarian or adrenal androgen secretion, or blocking androgen actions in the skin. The major drugs used are gonadotropin-releasing hormone (GnRH) agonists, combined oral contraceptives (COCs), and steroidal (cyproterone acetate and spironolactone) or nonsteroidal (flutamide and finasteride) antiandrogens. GnRH agonists, suppressing the pituitary, decrease androgen and estradiol secretion and improve severe hirsutism. To avoid estrogen deficiency problems, 'add back' therapy with estrogen-progestogen or COCs is advisable. This method of treatment is complicated and expensive, limiting its use to severe forms of ovarian hyperandrogenism with hyperinsulinemia. The third-generation COCs, containing new progestogens or cyproterone, have very restricted effectiveness in the short term (6 cycles), but their long term use (> 12 cycles) cures mild-to-moderate hirsutism and improves severe hirsutism. As well as suppressing gonadotropins and ovarian androgen steroidogenesis, these formulations decrease free testosterone levels and may also decrease adrenal androgen production. In women being treated with antiandrogens, COCs are important to provide control of the menstrual cycle and contraception. Cyproterone, a progestational agent, inhibits gonadotropin secretion and blocks androgen action. It is used in COCs or in a reverse sequential regimen. In the latter, it is very effective in the short term treatment of hirsutism. Spironolactone blocks androgen receptors. Its effectiveness in hirsutism is dosage-dependent: low dosages are less active than other antiandrogens, whereas high dosages (200 mg/day) are very effective at the cost of several adverse effects (particularly dysfunctional uterine bleeding), but the concomitant use of a COC may prevent these. Flutamide is a pure antiandrogen that blocks androgen receptors and inhibits hair growth. It is very effective in treating hirsutism within 6 to 12 months. Dry skin is very frequent during treatment with flutamide, and hepatotoxicity is possible at high dosages. Finasteride, a 5 alpha-reductase type 2 inhibitor, is the least effective antiandrogen, but a dosage of 5 mg/day decreases hirsutism without adverse effects. Pregnancy must be avoided during therapy with antiandrogens because of the possible risk of abnormal development of a male fetus. Antiandrogens, especially flutamide (250 to 500 mg/day) and cyproterone (12.5 to 50 mg/day in a reverse sequential regimen), alone or in association with COCs, seem to be the most effective agents for the treatment of hirsutism.